Hand Carry Application
Please fill out this application to request supplies from SOS to carry as extra luggage (“hand-carry”) on
an overseas flight for your mission trip. To begin the evaluation process to be able to use the SOS
“Medical Team Store” to pack your hand-carry for your mission trip, please fill in and return this form
and email or fax to SOS. Due to limited SOS staff, please allow enough time prior to your mission trip
to have application approved and your appointment scheduled to use the SOS Medical Team Store.
Before you fill in the request form, read the requirements to determine if your project will meet the
mission for use of the SOS Medical Team Store.
SOS Hand Carry Store Process
1. Read - Potential applicant reads all information about the SOS Hand Carry Program.
2. Application Submittal - Potential applicant fills out application that includes a list of supplies
needed, preferably 3-months before mission trip.
3. Applicant is notified by SOS that their application was approved.
4. Appointment - Upon application approval, SOS will contact approved applicant to schedule
appointment to use SOS Medical Team Store and to meet with SOS Marketing & Development
Director. Please note that due to demand, this may take up to two weeks.
5. Pay Fee - Applicant is prepared to pay administrative fee at time of appointment.
6. Applicant must take all medical supply items with them after payment
7. Documentation - Applicant provides the post-trip Hand Carry Report, including photos.
Documentation is required as part of this process and due upon return from mission trip.
1. Primary Contact
A. List the person who is requesting an appointment with SOS to use the Medical Team Store.
Name _________________________________________________________________________
Title ___________________________________________________________________________
Organization/Company ___________________________________________________________
Occupation _____________________________________________________________________
Connection to Mission Trip ________________________________________________________
Permanent Address ______________________________________________________________
______________________________________________________________
Phone (home) _________________ (work)_________________ (cell)___________________
E-mail _________________________________________________________________________
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B. Approximately what volume of supplies would you like to request from SOS? (You can express
this figure as a number of suitcase loads, number of boxes, maximum weight, etc.)
______________________________________________________________________________
2. Mission Trip Leader/Medical Professional Responsible for Supplies
A. Please list the name of the person heading the delegation of your mission trip:
Name _________________________________________________________________________
Title ___________________________________________________________________________
Organization/Company ___________________________________________________________
Occupation _____________________________________________________________________
Connection to Mission Trip ________________________________________________________
Permanent Address ______________________________________________________________
______________________________________________________________
Phone (home) _________________ (work)_________________ (cell)___________________
E-mail _________________________________________________________________________
B. Please list the name of the medical professional, either traveling or at the destination facility,
who will be responsible for the donated medical supplies:
_____ There is a medical professional and the information is below.
_____ The medical professional is the same as the primary contact.
_____ There is NO medical professional associated with this trip.
Name _________________________________________________________________________
Title ___________________________________________________________________________
Organization/Company ___________________________________________________________
E-mail _________________________________________________________________________
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3. Affiliation of Medical Mission
Please provide information about the institution, facility or location where the medical supplies will
be utilized.
Agency/Church Affiliation of Trip____________________________________________________
Website _______________________________________________________________________
Overseas Contact Person __________________________________________________________
Overseas Contact Email ___________________________________________________________
Destination Facility Name__________________________________________________________
Destination City _________________________________________________________________
Destination Country ______________________________________________________________
4. Mission Trip Details
Departure Date ________________________ Return Date _____________________________
Briefly describe the nature of your trip__________________________________________________
__________________________________________________________________________________
Number of team members traveling on this mission trip ___________________________________
What are the major health problems to be treated during this trip? __________________________
__________________________________________________________________________________
What is the estimated number of patients to be treated during this trip? _____________________
5. SOS Feedback Information
Have you or other group members received assistance from SOS in past? _____________________
If yes, when? ______________________________________________________________________
How did you hear about SOS? _________________________________________________________
1500 Arlington Avenue ı Louisville, KY 40206 ı 502-736-6360 ı www.SuppliesOverSeas.org
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6. Supply Request List
Fill out the form below and list the supplies your mission team would like to obtain from the SOS
Medical Team Store, or attach a typed list and submit with your application.
Quantity
Size
Category
Item
Notes
Will Accept item NonSterile
EXAMPLE
1 box of 100
M
Gloves
Exam gloves
Be as specific as possible in this section,
for example: No Latex.
EXAMPLE
1/box of 100
L
Gloves
Surgery gloves
Prefer Nitrile
If we only have the item you
want in non-sterile, will you
take it? If yes, put check here.
no
EXAMPLE
1000
4”x4”
Dressing
Prefer Sterile
Yes
1500 Arlington Avenue ı Louisville, KY 40206 ı 502-736-6360 ı www.SuppliesOverSeas.org
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7. Recipient Agreement
Application must be signed showing agreement with documentation and release below.
Documentation/Accountability
SOS has received medical surplus supplies from a variety of donors. Through the donor’s generosity, SOS is able to share cost-saving and
life-saving materials. For this reason, we must document to our donors how their supplies are being used. So that SOS can improve future
services, applicant will also receive a post-trip evaluation survey that is due upon return of mission trip.
PHOTOGRAPHS: All organizations requesting SOS supplies and equipment must document the final destination of the supplies by taking
photographs of the clinic or hospital using the supplies. Photos should include, but are not limited to: an outside shot of the clinic/hospital;
clinic/hospital signage; inside of the clinic/hospital; unpacking the supplies; supplies being put on shelving; and the public being served by
the supplies.
WRITTEN DOCUMENTATION: Recipients are required to submit to a narrative summary of the trip/ how supplies were used and
the impact of SOS’s donation to improve health care delivery for the clinic/hospital.
FORWARD: Photos and written documentation should be sent to [email protected]
FUTURE SHIPMENTS: Because this documentation is so important to the future success of SOS, failure to supply photos or written
documentation may result in the requesting organization’s ability to apply for supplies in the future.
Release and Indemnity
The medical supplies, equipment, materials and other items (“Materials”) available from Supplies Over Seas (“SOS”) are items that would have been
discarded or otherwise disposed of by hospitals or health care providers in the United States. These Materials are being made available strictly on an “as is”
basis for humanitarian use in circumstances in which sufficient alternative sources of such resources are not available. The recipient organization recognizes
that SOS and the donor facilities do not make any representations or warranties, either express or implied, as to the condition of the Materials, and further
recognizes that SOS and the donor facilities make no representations or warranties, express or implied, that the Materials are fit, appropriate, free from
defects, sterile, pure, operable, or otherwise suitable for any intended purpose. The recipient organization accepts the Materials “as is,” with all faults, and
acknowledges that the inspection for any defects and the safe operation of said Materials is solely the responsibility of the recipient organization. Each
recipient organization, recipient facility, and responsible manager of such entities assumes full responsibility for making an independent determination of
the appropriateness of the Materials (or any part thereof) before using them, and for discarding any Materials which are not appropriate for use. Under no
circumstances shall SOS, the manufacturer or distributor of the Materials, or any United States hospital or health care provider that ever owned or used the
donated equipment, be liable to recipient organization or anyone for any direct, special, indirect, incidental, or consequential loss or damage resulting from
the Materials or their use. To the maximum extent permitted by law, the recipient organization fully accepts and assumes all risks and all responsibility for
losses, costs, and damages that the recipient organization, its agents, representatives, members, directors, officers, employees, agents, contractors, patients,
and transferees (“Users”) may incur as a result of the Materials or their use, including without limitation personal injuries, illness, damage, loss to property,
and death. SOS and the recipient organization recognize that this agreement shall release SOS and the donor facilities from any and all liability for personal
injury and/or any other type of injury arising from the use of the Materials. The recipient organization acknowledges that the consideration for this release
and indemnification is the donation of the Materials themselves. By making an application for the receipt of such Materials and by accepting such Materials,
the recipient organization, to the maximum extent permitted by law, fully releases, acquits, and forever discharges SOS, the donor facilities, and each and
every past and present subsidiary, affiliate, officer, director, agent, servant, employee, trustee, and representative of SOS and the donor facilities (“Released
Persons and Entities”) from any and all loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses of any
kind, character, or nature whatsoever, known or unknown, fixed or contingent, which might arise from or be related or associated in any way with the
Materials or their use, including but not limited to any injury, illness, disease, property damage, death, or loss of any nature suffered or sustained in
connection with the use or possession of the Materials. To the maximum extent permitted by law, the recipient organization also agrees to indemnify, save,
and hold the Released Persons and Entities harmless for any loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs
and expenses (including attorneys’ fees) of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which may be incurred arising
out of or related to the use or possession of the Materials, regardless of the nature or the extent of the injury, illness, disease, property damage, death, or
loss, and regardless of whether it results from the negligence of the Users or of the Released Persons and Entities.
I, _______________________________________ guarantee that the supplies I receive as donations from Supplies Over Seas,
(Contact Person for Consignee)
will be used for ___________________________________________________________________ to benefit patients in need.
(Healthcare Institution)
I understand that these supplies are donated, have no commercial value, and therefore I will not sell or exchange these items for profit or gain. I further
attest that I have read and agree to receive donated items from SOS according to the stipulations above. The recipient organization agrees to provide SOS
with photos and feedback whenever possible related to how the medical supplies and equipment from this shipment are used. The recipient organization
gives SOS permission to use stories, photos and video related to this shipment for marketing and fundraising purposes.
If the undersigned is an entity, the undersigned represents and warrants that the undersigned has the authority to commit the entity on whose behalf the
undersigned is signing this document. I have thoroughly read the Hand Carry Program Description.
Signature_____________________________________________________________________________
Print Name __________________________________________
Date _________________
Application must be signed showing agreement with documentation and release.
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8. Application Submittal
Submit the completed & signed application including the list of requested supplies. Ensure all pages
1-5 are scanned and emailed or faxed to:
By email:
[email protected]
By mail:
Supplies Over Seas
1500 Arlington Avenue
Louisville, KY 40206
USA
Questions:
(502) 736-6360 SOS Headquarters
(502) 939-6641 cell phone
1500 Arlington Avenue ı Louisville, KY 40206 ı 502-736-6360 ı www.SuppliesOverSeas.org
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SOS Application Processing - HAND CARRY
Processing information to be filled out by Supplies Over Seas after application is approved.
_________________________________
Primary Contact Name
_________________________________
Name of SOS staff member who approved application
_________________________________
Day/Date of SOS Medical Team Store Appointment
_________________________________
Time of SOS Medical Team Store Appointment
Administrative Fee
While our healthcare partners donate the surplus medical supplies to Supplies Over Seas, recipients or
their sponsors are asked to pay an administrative fee/SOS Donation to help cover some of the costs of
our operations and ensure that we have the supplies to meet your needs.
The Hand Carry administrative fee/SOS Donation of $50.00 covers the first 50 lbs. of hand-carry items.
An additional fee of $2.00 per pound is assessed for weight above 50 pounds.
__________
Total Weight
$
Medical Team Store fee for 50 pounds
50.00
$ _________
Weight in excess of 50 pounds = _________ x $2.00
$ _________
Donation - Additional Donation made to Supplies Over Seas
_____________________________________________________________
$ _________
Total Due
Payment Method
Supplies Over Seas is a 501(c)(3) nonprofit organization. All donations are tax deductible as provided by
law.
___________________ Cash
___________________ Check
Please make checks payable to “Supplies Over Seas”
___________________ Credit Card Credit card payment made online at:
www.SuppliesOverSeas/donate/money
__________________ Hand Carry Report Packet handed to Applicant & Dot on Map/Photo Taken
Staff Notes
_____________________________________________________________________________________
_____________________________________________________________________________________
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